Informatización de los registros de enfermería en el proceso quirúrgico¿se contempla toda la información?

  1. Gema García Fernández
  2. De la Vega García, Jorge
  3. Castro Celeiro, Eva
  4. Álvarez Coro, Carlos
Journal:
Revista de la Asociación Española de Enfermería Quirúrgica

ISSN: 1885-2548

Year of publication: 2016

Issue: 39

Pages: 23-31

Type: Article

More publications in: Revista de la Asociación Española de Enfermería Quirúrgica

Abstract

INTRODUCTION: Information systems provide effectiveness and efficiency to the care process and increase patient safety1, 2. More and more hospitals tend to replace paper records with electronic health records (EHR)3. In 2014 the Asturias Central University Hospital implemented EHR through the Millenium program, developing unique computer applications depending on the scope of the patient. For the surgical process, where surgical nursing records intraoperative care, SurgiNet is used. The importance of this documentation justifies the need to assess whether all the information recorded on paper is also digitized now. OBJECTIVE: To assess the degree of overlap between paper and digital records. MATERIALS AND METHODS: Compilation of paper nursing records in operating theatres. Analysis of the records made with SurgiNet after one year of implementation. Descriptive cross-sectional study comparing both records. RESULTS: Information from 158 variables in paper records and 163 in SurgiNet was obtained. Taking as reference the paper format, a 91.1% degree of coincidence with SurgiNet was observed (of the 158 items available on paper, all of them were in digital format as well, except 14). As for the digital format, the match was lower (88%), as SurgiNet made possible the registration of 10 new information areas not previously considered on paper. Besides, changes were identified in the way 36 of the 133 items in both formats were documented. CONCLUSIONS: The SurgiNet application allows surgical nursing to register information that was previously collected on paper, but with exceptions, which means the latter format must be kept. It makes the documentation of new information possible and of cross-section data easier in all fields in a different way as it was done on paper.